juggling

Some peculiarity in the schedule this year has arranged that I’ve spent most of my time so far on rotations which are not part of the general call pool; and when I have been in the call schedule, it’s mostly been for the short, 12-hour shifts. So handling all the surgical services at night is still a little new to me. The last such night went much better than I had expected, and seems to augur well for the next month, which will be all nights. (You’ll have to excuse some elaborate phrases; I’m reading Mallinson and O’Brian, historical novelists of the British cavalry and navy in the early 1800s, and their latinate constructions are catching.)

One of the first highlights was a call from the OR holding area: “The vascular patient your attending is expecting has arrived, direct by ambulance.” Which did not sound good: a patient being admitted directly to the OR for vascular surgery? And of course the attending, having said that he would take the patient, and informed the OR, had not felt a need to tell the residents about it. Fortunately, a tourniquet, although limb-threatening, had the bleeding well under control.

A little later things became more complicated. One intern had a patient on the floor with progressive shortness of breath and hypertension, while supposedly hemorrhaging – altogether a puzzling picture. While he was being transferred to the ICU, the other intern called me with a patient in the ER, who had a dramatic CT scan and peritonitis. By the time I got down to the ER, the patient was unwilling to talk much; whether because she was tired of explaining to multiple doctors, or because she was actually so ill, was unclear to me. But she had rebound on exam, and the CT was clear, so I called the attending and the chief resident to come in from home, and told the OR to set up for them.

No sooner had that been settled, than the first intern called again to say his patient was struggling to breathe, and had an ABG on which the CO2 was nearly three times normal, whereas the O2 was one-third normal, and he was going to call anesthesia to intubate him. At our hospital, because of the presence of an anesthesia residency, anesthesia is responsible for all intubations – if they arrive in time. For a few minutes after I got upstair, as we were bagging the patient in an attempt to correct an oxygen saturation of 60% (which had developed after the intern called me), I thought I would really have to use the intubation kit which is kept in all the ICUs, and do it myself. However, anesthesia did arrive quickly enough that it was still safer to wait for them than to try it myself, and the patient was soon intubated and stable.

Which is an example of my dangerous inability to believe maxims without testing them for myself; like reinventing the wheel constantly. There’s an old saying: if you think about intubating the patient, just do it – don’t wait for things to get worse. And I had thought about it, after getting that man down to the ICU, before I left for the ER. His sats and blood pressure were fine, he just looked labored. I had thought he could wait a few more hours, or perhaps might improve with more aggressive care in the ICU. In this instance, the delay didn’t hurt anything, except that it created a commotion and meant the patient had to be intubated as an emergency. Next time, I would order the intubation a lot sooner. And for the future, I swear I’m going to actually follow all those maxims, rather than discovering them for myself.

After that the intern and I put in a line together. Which was for me a significant point: the first time I’ve guided an intern, not comfortable with lines, through the procedure by myself. That sounds ridiculous, for surgery residents more than halfway through the academic year. But picc lines (peripherally inserted central catheters) are so ubiquitous now that only in true emergencies in the middle of the night do we usually place central lines any more.

The rest of the night, while busy, was calm compared to that. No deaths on my watch, which was a relief after the last few calls, and after the signout I’d gotten on some of the more precarious ICU patients.

i just have to say that i really enjoy your blog. i think i’ll ultimately go into pediatrics, so surgery is a far cry for me, but i really appreciate reading your descriptions of what you do as a resident. and it’s exciting to see (or read) how you become more independent and more sure of yourself. thanks for sharing.